Professional Documents
Culture Documents
Table 1-1. AHA/NHLBI, IDF, and WHO Metabolic Syndrome Diagnostic Criteria
AHA/NHLBI IDF WHO
Number of Any 3 of 5 below Abdominal obesity plus 2 Type 2 diabetes mellitus,a IFG,b
required criteria others below IGT,c or lowered insulin
sensitivityd plus 2 others below
Abdominal obesity Waist circumference ≥ 102 cm in Increased waist circumference Waist-to-hip ratio of > 0.90 in men
men or ≥ 88 cm in women (population-specifice [e.g., or > 0.85 in women and/or BMI
Europid ≥ 94 cm in men or ≥ 80 > 30 kg/m 2
cm in women])
Elevated triglycerides ≥ 150 mg/dL, or drug treatment for ≥ 150 mg/dL, or drug treatment for ≥ 150 mg/dL
high triglycerides (i.e., fibrates or high triglycerides (i.e., fibrates or
nicotinic acid) nicotinic acid)
Low HDL-C < 40 mg/dL in men or < 50 mg/dL in < 40 mg/dL in men or < 50 mg/dL in < 35 mg/dL in men or < 39 mg/dL
women; or drug treatment for low women; or drug treatment for low in women
HDL-C (i.e., fibrates or nicotinic HDL-C (i.e., fibrates or nicotinic
acid) acid)
Elevated blood Systolic ≥ 130 mm Hg and/or Systolic ≥ 130 mm Hg and/or ≥ 140/90 mm/Hg
pressure diastolic ≥ 85 mm Hg; or drug diastolic ≥ 85 mm Hg; or drug
treatment for hypertension treatment for hypertension
Elevated fasting ≥ 100 mg/dL; or drug treatment for ≥ 100 mg/dL; or drug treatment for Required, see first row in
plasma glucose elevated glucose elevated glucose this column
Other – – Microalbuminuria ≥ 20 mcg/
minute or albumin-to-creatinine
ratio ≥ 20 mg/g
a
Type 2 diabetes mellitus = fasting plasma glucose of 126 mg/dL or greater or 2-hour post load glucose of 200 mg/dL or greater.
b
Impaired fasting glucose = fasting plasma glucose between 110 mg/dL and 125 mg/dL and 2-hour post load glucose less than 140 mg/dL. The American
Diabetes Association has since revised the definition of IFG to be fasting plasma glucose between 100 mg/dL and 125 mg/dL.
c
Impaired glucose tolerance = fasting plasma glucose less than 126 mg/dL and 2-hour post load glucose between 140 mg/dL and 199 mg/dL.
d
Insulin sensitivity glucose uptake below the lowest quartile for background population under investigation, as measured under hyperinsulinemic
euglycemic clamp conditions.
e
Europid ≥ 94 cm men or ≥ 80 cm women; South Asian and Chinese ≥ 90 cm men or ≥ 80 cm women; Japanese ≥ 85 cm men or ≥ 90 cm women; ethnic
South and Central Americans ≥ 90 cm men or ≥ 80 cm women; Sub-Saharan Africans ≥ 94 cm men or ≥ 80 cm women; Eastern Mediterranean and
Middle East (Arab) populations ≥ 94 cm men or ≥ 80 cm women.
AHA/NHLBI = American Heart Association/National Heart, Lung and Blood Institute; BMI = body mass index; HDL-C = high-density lipoprotein
cholesterol; IDF = International Diabetes Federation; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; WHO = World Health
Organization.
Information from the American Heart Association/National Heart, Lung, and Blood Institute metabolic syndrome diagnostic criteria; International
Diabetes Federation metabolic syndrome definition, and World Health Organization metabolic syndrome definition.
degree of weight loss can be achieved by reducing caloric fasting plasma glucose and the greatest improvement in
intake by 500–1000 calories per day and increasing physical insulin sensitivity.
activity. The physical activity component should focus on Another study compared the effectiveness of four popular
the accumulation of 30–60 minutes of moderate-intensity diets: Atkins (carbohydrate restriction), Zone (macronutrient
exercise coupled with increased daily lifestyle activities (e.g., balance), Weight Watchers (calorie restriction), and Ornish
pedometer step tracking, gardening, housework) for 5 days/ (fat restriction). After 1 year of intervention, weight loss did
week or more. Exercise stress testing should be performed not differ significantly between the diet groups. Notably,
before initiating an exercise program in individuals with more patients prematurely discontinued the Atkins and
existing cardiovascular disease, recent acute coronary Ornish diets (48% and 50%, respectively) compared with
syndrome, or recent revascularization. the Weight Watchers and Zone diets (35% discontinuation
Regarding weight loss, the most common question both in both groups). Taken together, these studies suggest that
patients and health care practitioners pose is: Which type of selection of a diet based solely on the anticipated amount
diet is most effective? Although no consensus exists about of weight loss is not enough. Instead, consideration must
which diet is most effective for patients with metabolic be given to patient food preferences and the likelihood
syndrome, data suggest that a Mediterranean-style diet may of patient adherence. Diets such as the Weight Watchers
be particularly beneficial in this population. Mediterranean- program or a Mediterranean-style diet, which incorporate
style diets incorporate foods rich in monounsaturated a variety of food choices that can be tailored to different
fats (e.g., olive oil) and omega-3 fatty acids (e.g., fish). In lifestyles or medical conditions, may prove to be the best
addition, these diets include daily amounts of fruit (250–300 means for successful and long-term weight loss.
g), vegetables (125–250 g), nuts (25–50 g), and low-fat whole Patients often request pharmacologic therapy to assist
grains (400 g). A study of patients with metabolic syndrome in their weight-loss endeavors. However, weight-loss drugs
found that after 2 years of intervention, a Mediterranean- have limited use in patients with metabolic syndrome
style diet was associated with a significantly greater amount because these agents cause only 3% to 5% greater weight
of weight loss than a control diet (−4.0 kg vs. −1.2 kg). In loss compared with placebo. In addition, pharmacologic
this study, the Mediterranean-style diet also favorably weight-loss drugs are associated with significant adverse
modulated metabolic risk factors such as inflammatory effects. Agents such as orlistat, sibutramine, phentermine,
cytokines and insulin sensitivity. At the end of the study, or diethylpropion are usually reserved as adjuncts to diet
metabolic syndrome was still present in 44% of patients in and exercise in patients with a BMI greater than 30 kg/m 2
the Mediterranean-style diet group compared with 87% of whose diet and exercise alone have not resulted in sufficient
patients in the control group. weight loss. Pharmacologic therapy may be considered for
Recently, a clinical study compared Mediterranean-style, individuals with a BMI between 27 kg/m2 and 30 kg/m2
low-fat, and low-carbohydrate diets. Study participants if obesity-related disease (e.g., type 2 DM, cardiovascular
were moderately obese and had many metabolic risk disease, hypertension, dyslipidemia, sleep apnea) is present
factors. After 2 years, weight loss was greater with the and diet and exercise alone have not worked.
nonrestricted-calorie low-carbohydrate diet (−4.7 kg) and When selecting a pharmacologic weight-loss agent,
the restricted-calorie Mediterranean diet (−4.4 kg) compared careful consideration must be given to the adverse effect
with the restricted-calorie low-fat diet (−2.9 kg). Subgroup profile and any contraindications to therapy. Orlistat is
analysis showed that the low-carbohydrate diet had the an intestinal lipase inhibitor that decreases dietary fat
most favorable effect on lipids, whereas the Mediterranean- absorption by 30%. Patient adherence to orlistat is typically
style diet was associated with the largest decrease in poor because of significant gastrointestinal adverse
Existing type 2
Determine 10-year Framingham risk No Yes
diabetes or
ASCVD?
7. Given A.K.’s clinical and social history, which one of 11. Which one of the following patients with metabolic
the following is the best diet plan to recommend? syndrome is the best candidate for bariatric surgery,
A. Nonrestricted-calorie, low-fat diet. assuming lifestyle interventions have failed to achieve
B. Restricted-calorie, Mediterranean-style diet. the desired weight loss?
C. Nonrestricted-calorie, low-carbohydrate diet. A. A patient with fasting plasma glucose of 90 mg/dL,
D. Restricted-calorie, liquid shake diet. BMI of 35 kg/m 2, and binge-eating disorder.
B. A patient with fasting plasma glucose of 118 mg/
8. D.B. is a 58-year-old obese man with a medical history dL, BMI of 37 kg/m 2, and unstable angina.
significant for metabolic syndrome, uncontrolled C. A patient with fasting plasma glucose of 184 mg/
hypertension, prediabetes, depression, and anxiety. dL, BMI of 39 kg/m 2, and sleep apnea.
Through diet and exercise alone, for the past 7 months, D. A patient with fasting plasma glucose of 229 mg/
D.B. has lost 6.4 kg. Currently, his BMI is 32 kg/m 2, dL, BMI of 41 kg/m 2, and bipolar manic depression.
weight is 103.6 kg, and waist circumference is 112
cm. Despite his efforts, D.B. has not achieved his 12. C.M. is a 66-year-old white man with a BMI of 23
weight-loss goals with diet and exercise alone. D.B. is kg/m 2, waist circumference of 81 cm, HDL-C 47 mg/
frustrated that his weight loss has reached a plateau, dL, triglycerides 138 mg/dL, fasting plasma glucose
and he asks if there are any drugs that would help him 112 mg/dL, and blood pressure of 128/76 mm Hg.
lose more weight. Which one of the following is the best His current drugs are fenofibrate 120 mg once daily,
pharmacologic intervention to augment D.B.’s diet and tamsulosin 0.4 mg once daily, and ibuprofen as needed
exercise program? for back pain. Using metabolic syndrome diagnostic
A. Phentermine. criteria, which one of the following statements is most
B. Orlistat. accurate regarding C.M.?
C. Sibutramine. A. He has metabolic syndrome according to American
D. Metformin. Heart Association/National Heart, Lung and Blood
Institute (AHA/NHLBI) criteria.
9. J.N. is a 47-year-old man with type 2 DM who recently B. He has metabolic syndrome according to
completed participation in a Phase III clinical trial of a International Diabetes Federation (IDF) criteria.
novel, dual peroxisome proliferator–activated receptor C. He has metabolic syndrome according to World
(PPAR)g/PPARa agonist. He took an active study Health Organization (WHO) criteria.
drug for 24 weeks with no major adverse events. From
D. He does not have metabolic syndrome.
baseline to week 24, which one of the following would
be the most likely observed metabolic effect of the dual
Questions 13 and 14 pertain to the following case.
PPARg/PPARa agonist?
T.K. is a 55-year-old obese man with metabolic syndrome,
A. Decrease in triglycerides from 220 mg/dL to 160 osteoarthritis, type 2 DM, and a history of myocardial
mg/dL. infarction. His stress test is normal. Through dietary
B. Decrease in blood pressure from 140/90 mm Hg to changes alone, his weight decreased from 132 kg to 114 kg,
128/74 mm Hg. and his waist circumference decreased from 132 cm to 112
C. Decrease in total body weight from 118 kg to 105 cm during a period of 8 months.
kg.
D. Decrease in serum creatinine from 1.5 mg/dL to
0.9 mg/dL. 13. Which one of the following is the best next step
regarding T.K.’s lifestyle-intervention plan?
10. S.T. is a 65-year-old man with type 2 DM, metabolic A. No change is recommended because the patient has
syndrome, and congestive heart failure (New York Heart already met appropriate weight-loss goals.
Association class III). His diabetes is uncontrolled, B. Initiate jogging (5 miles/hour) for 10 minutes three
and his hemoglobin A1C is 7.8%. S.T. currently takes times/week.
glyburide 10 mg two times/day. His BMI is 36 kg/ C. Initiate swimming for 30 minutes three times/
m2, waist circumference is 109 cm, blood pressure is week.
142/86 mm Hg, and serum creatinine is 1.7 mg/dL. His D. Participate in gardening for 60 minutes three
lipid panel shows the following: HDL-C 44 mg/dL, times/week.
LDL-C 98 mg/dL, triglycerides 140 mg/dL, and total
cholesterol 170 mg/dL. Which one of the following is 14. Which one of the following is the best assessment of
the best agent to add to his current diabetes regimen thiazolidinedione use in T.K?